Low-Value Care Determinants

By April 24, 2017 Commentary

Assuming you believe the delivery of “low-value” care is a problem, you would want to figure out how to limit its use.  It would help to know who is more likely to deliver than low-value care and why.  Research in the Journal of the American Medical Association Internal Medicine addresses that question.  (JAMA Int. Med. Article)    Low-value services for this study were antibiotic use for upper respiratory tract infections, back pain imaging and headache imaging.  Specialty referrals were a secondary indicator of low-value use analyzed.  Using survey data from the period 1997 to 2013, and information about practice ownership, the researchers looked for links between practice structure and use of low-value services.  They compared hospital-owned and based practices, hospital-owned but community-based primary care practices and independent primary care doctors.  The analysis was adjusted for a variety of demographic and health-status factors.  Patients seen in all the types of practices were generally similar, although hospital-based practices generally saw younger patients and more often the physicians in those practices were not the patients usual primary care doctor.

Antibiotic use was similar across locations.  Imaging use for both of the other low-value services was higher at hospital owned practices by several percent and specialty referrals were much more frequent.  In hospital-based practices, seeing a primary care physician who was not the patient’s usual PCP was associated with a five-fold increase in specialty referrals and a greater use of imaging.  The difference in use and referrals continued over time.  The results suggest that continuity of care with the same primary care physician can help reduce use of low-value care.  This is likely an issue of the doctor’s familiarity with specific patients.  The results also indicate that it is likely that doctors in hospital-based or owned practices feel some pressure to use other resources which are probably owned by the hospital.  No difference in antibiotic use, where there wouldn’t be a benefit to the hospital, but a difference in imaging, which likely does benefit a hospital.  And referrals are probably being made to other physicians employed or owned by the hospital.  Just another reason to ban hospital ownership of physician practices.

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